MR. LITTLEWOOD

BRIEF ENCOUNTERS

MR. LITTLEWOOD

Mr Littlewood sat calmly on a straight-backed chair in his small hospital room. He was pale and gaunt and reminded me immediately of the Grail Knight from Indiana Jones and the Last Crusade. He looked as if he might have been waiting for me with perfect composure for several centuries.

Running across his chest and up into his left nostril was a slender tube. Seeing my eye fall on it, he explained, in a dry, matter-of-fact voice ‘It’s a naso-gastric tube. The staff bring my meals in a syringe three times a day and squirt them into me. Not an ideal arrangement but it keeps me alive, I suppose’.

I wondered why he didn’t just eat? He sighed like a teacher trying to explain long division to the captain of the school rugby team. ‘I’m on hunger strike’ he said wearily.

I asked him why he thought he was in a psychiatric hospital. He chuckled humourlessly. ‘Well. They say I have schizophrenia, which is obviously rubbish. I’m on no psychotropic medication, and I have no symptoms whatsoever… I suspect that I’m being held here at the behest of the U.S. Government to prevent me from continuing my work’.

I knew I was going to regret it, but I had to ask: What work? ‘Synergic fusion. I can generate unlimited quantities of energy from the Earth’s magnetic field. Perfectly clean, completely free energy. I have all the calculations here…’.

Half an hour later, my head spinning with impenetrable algebra, I went to the ward office to look at Mr Littlewood’s notes.

At this point in history, notes were still handwritten, and entries fell into three categories: Loopy, Cuneiform and Consultant. Consultant entries looked as if someone had tied a biro to a lobster’s back leg and let it wander around for a bit; Cuneiform notes were written with a ruler (Why? Why??) so that all the letters looked the same and you were never sure if your client had drinking probs or chicken pox; Loopy writing was big and friendly and belonged on a birthday card for an eight-year-old, but you could read it.

One loopy entry caught my attention: Antipsychotic Administered as Per Policy. Intrigued, I turned to the Consent to Treatment section of the notes.

A person detained under section 3 can be given medication for three months whether they like it or not, even if they have capacity to choose; after three months however the hospital has to either get their consent or seek the approval of a Second Opinion Approved Doctor (SOAD), appointed by the CQC. Mr Littlewood was deemed incapable of giving valid consent, so a SOAD had approved the covert administration of antipsychotic medication ‘up to 150% of the BNF maximum’. In short, Mr Littlewood was on a shedload of antipsychotics and didn’t know it.

Covert medication of psychiatric patients is not uncommon on dementia wards, where patients are confused and it’s really just the path of least resistance. It’s much less common on general psychiatric wards, not least because many psychotropic drugs are available in injectable form, so unwilling patients can be restrained and medicated ‘IM’ – that is, intramuscularly. However not all medications come with a syringe option; sometimes, too, patients are too frail to be restrained safely. This was the case with Mr Littlewood: he had a heart condition which made the staff very reluctant to wrestle him to the ground in four-point restraints.

But there was a dilemma here. Mr Littlewood quite logically attributed his lack of symptoms to not being schizophrenic, whereas it was actually due to 150% of the maximum dose of potent pharmaceutical coursing through his veins doing its stuff. In this circumstance, how could he be expected to have ‘insight’? How could he meaningfully consent? More pressingly, he had a Tribunal coming up and he would be the only person in the room who didn’t know the truth.

The Tribunal reports were predictably marked ‘not for disclosure to the patient’. Under the Tribunal Rules, the legal representative is bound by this in the short term, but the presumption is in favour of disclosure unless it is likely to cause serious harm, and the judge on the day is quite likely to order disclosure. So if you’re the author of a report and you don’t want the patient to see something, better not to put it in.

As well as the Rules, there was also case law. In RM v St Andrew’s Healthcare [2010] UKUT 119, the Upper Tribunal ruled that the patient must be told about his covert medication, even if this damaged his therapeutic relationship with the treating team. Otherwise, Judge Jacobs opined, the Tribunal hearing would be a sham – ‘a pretence of a process’.

Sure enough the judge ordered that Mr Littlewood must be told. Told that the staff had been injecting antipsychotic into his stomach along with butterscotch flavoured Ensure Plus; told that the reason for his lack of symptoms was the presence of sophisticated drugs, not the absence of illness. In a cramped side-room I told him the news and waited anxiously for his reaction. He gave an arid laugh. ‘Do they expect me to believe that? Ridiculous!’. ■

Andy Howarth

Andy Howarth is a Solicitor in the Mental Health Department at GHP Legal solicitors.